Considering syphilis and HIV in differential diagnoses

All rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

I read with interest Dr. Elangasinghe's letter promoting more widespread syphilis and HIV testing. NICE guidance changed in 2016 to include the recommendation that all patients admitted to hospital in an area of high HIV prevalence who are having blood tests for any reason should also be offered a HIV test (1). Although this practice has been adapted in many general hospitals, it appears not to have yet become common place in mental health.

Recent snapshot audits conducted by two of the authors (KD and GS) in two inpatient units in high prevalence areas in the South of England (Reading and Milton Keynes) confirm this, with no patients being tested within one week of admission to the unit at either site, and poor documentation of risk-factors for blood-borne virus infection. The epidemiology of HIV infection amongst mental health patients is complex, with rates differing depending on diagnosis and co-morbid substance use (2), but large observational studies consistently demonstrate an increased rate of HIV infection amongst mental health patients (3). The converse is also true: people infected with HIV have higher rates of mental illness than the general population (4). This implies that we should be no less pro-active in encouraging testing in this population than in the general hospital.

We conducted qualitative research during the course of this audit to identify barriers to HIV testing. Most notable was the finding that doctors were reluctant to offer testing because of concerns about capacity, consent and the requirement for pre-test counselling in our patient population. Specific concerns included: 1. The belief that written consent is required for a HIV test. This is not the case - verbal consent is sufficient (5). 2. The belief that extensive pre-test counselling is required. It is not - the crucial information that must be shared is (i) the benefits of being tested and (ii) how and when the patient will receive the results (5). 3. Some doctors were concerned about the assessment of capacity to consent to HIV testing. Capacity to consent to a HIV test is assessed in the same way as capacity to make any decision (5). At the Milton Keynes site, we aimed to correct these misconceptions and introduce opt-out HIV testing for all acute psychiatric admissions. Following the introduction of simple education measures (teaching junior doctors in a 15 minute session about opt-out testing including appropriate counselling, and the production of a FAQ document directed at doctors) the proportion of new admissions tested for HIV increased to 87.5%. This work demonstrates that improved HIV testing rates in an inpatient psychiatric setting are acceptable to doctors and patients and achievable with simple quality-improvement measures. We believe that basic physical health interventions like this are a key part of achieving “parity of esteem” for physical and mental health.

REFERENCES 1. https://www.nice.org.uk/guidance/ng60, “HIV testing: increasing uptake among people who may have undiagnosed HIV”, published Dec. 2016, accessed 24/07/2017. 2. “Understanding Associations Between Serious Mental Illness and HIV Among Patients in the VA Health System”, Himelhoch et al. Psychiatric Services, 2007. 3. “Review of the evidence: prevalence of medical conditions in the United States population with serious mental illness”, Janssen et al., General hospital psychiatry, 2015. 4. “Psychiatric Disorders and Drug Use Among Human Immunodeficiency Virus– Infected Adults in the United States”, Bing et al., Archives of General Psychiatry, 2001. 5. “UK National Guidelines for HIV Testing 2008”, British HIV Association, 2008. Accessed 24/07/2017